Provider Demographics
NPI:1376825737
Name:DAVIS, LAEL LARRICE
Entity Type:Individual
Prefix:MRS
First Name:LAEL
Middle Name:LARRICE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 PLEASANT ST
Mailing Address - Street 2:#3
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1835
Mailing Address - Country:US
Mailing Address - Phone:857-246-0114
Mailing Address - Fax:
Practice Address - Street 1:85 PLEASANT ST
Practice Address - Street 2:#3
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-1835
Practice Address - Country:US
Practice Address - Phone:857-246-0114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS58610611347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle